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https://www.mayoclinic.org/diseases-conditions/colon-cancer/symptoms-causes/syc-20353669

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Overview

Colon cancer is a type of cancer that begins in the large intestine (colon). The colon is the final part of the digestive tract.

Colon cancer typically affects older adults, though it can happen at any age. It usually begins as small, noncancerous (benign) clumps of cells called polyps that form on the inside of the colon. Over time some of these polyps can become colon cancers.

Polyps may be small and produce few, if any, symptoms. For this reason, doctors recommend regular screening tests to help prevent colon cancer by identifying and removing polyps before they turn into cancer.

If colon cancer develops, many treatments are available to help control it, including surgery, radiation therapy and drug treatments, such as chemotherapy, targeted therapy and immunotherapy.

Colon cancer is sometimes called colorectal cancer, which is a term that combines colon cancer and rectal cancer, which begins in the rectum.

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Symptoms

Signs and symptoms of colon cancer include:

A persistent change in your bowel habits, including diarrhea or constipation or a change in the consistency of your stool

Rectal bleeding or blood in your stool

Persistent abdominal discomfort, such as cramps, gas or pain

A feeling that your bowel doesn't empty completely

Weakness or fatigue

Unexplained weight loss

Many people with colon cancer experience no symptoms in the early stages of the disease. When symptoms appear, they'll likely vary, depending on the cancer's size and location in your large intestine.

When to see a doctor

If you notice any persistent symptoms that worry you, make an appointment with your doctor.

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Causes

Doctors aren't certain what causes most colon cancers.

In general, colon cancer begins when healthy cells in the colon develop changes (mutations) in their DNA. A cell's DNA contains a set of instructions that tell a cell what to do.

Healthy cells grow and divide in an orderly way to keep your body functioning normally. But when a cell's DNA is damaged and becomes cancerous, cells continue to divide - even when new cells aren't needed. As the cells accumulate, they form a tumor.

With time, the cancer cells can grow to invade and destroy normal tissue nearby. And cancerous cells can travel to other parts of the body to form deposits there (metastasis).

Risk factors

Factors that may increase your risk of colon cancer include:

Older age. Colon cancer can be diagnosed at any age, but a majority of people with colon cancer are older than 50. The rates of colon cancer in people younger than 50 have been increasing, but doctors aren't sure why.

African-American race. African-Americans have a greater risk of colon cancer than do people of other races.

A personal history of colorectal cancer or polyps. If you've already had colon cancer or noncancerous colon polyps, you have a greater risk of colon cancer in the future.

Inflammatory intestinal conditions. Chronic inflammatory diseases of the colon, such as ulcerative colitis and Crohn's disease, can increase your risk of colon cancer.

Inherited syndromes that increase colon cancer risk. Some gene mutations passed through generations of your family can increase your risk of colon cancer significantly. Only a small percentage of colon cancers are linked to inherited genes. The most common inherited syndromes that increase colon cancer risk are familial adenomatous polyposis (FAP) and Lynch syndrome, which is also known as hereditary nonpolyposis colorectal cancer (HNPCC).

Family history of colon cancer. You're more likely to develop colon cancer if you have a blood relative who has had the disease. If more than one family member has colon cancer or rectal cancer, your risk is even greater.

Low-fiber, high-fat diet. Colon cancer and rectal cancer may be associated with a typical Western diet, which is low in fiber and high in fat and calories. Research in this area has had mixed results. Some studies have found an increased risk of colon cancer in people who eat diets high in red meat and processed meat.

A sedentary lifestyle. People who are inactive are more likely to develop colon cancer. Getting regular physical activity may reduce your risk of colon cancer.

Diabetes. People with diabetes or insulin resistance have an increased risk of colon cancer.

Obesity. People who are obese have an increased risk of colon cancer and an increased risk of dying of colon cancer when compared with people considered normal weight.

Smoking. People who smoke may have an increased risk of colon cancer.

Alcohol. Heavy use of alcohol increases your risk of colon cancer.

Radiation therapy for cancer. Radiation therapy directed at the abdomen to treat previous cancers increases the risk of colon cancer.

Prevention

Screening colon cancer

Doctors recommend that people with an average risk of colon cancer consider colon cancer screening around age 45. But people with an increased risk, such as those with a family history of colon cancer, should consider screening sooner.

Several screening options exist - each with its own benefits and drawbacks. Talk about your options with your doctor, and together you can decide which tests are appropriate for you.

Lifestyle changes to reduce your risk of colon cancer

You can take steps to reduce your risk of colon cancer by making changes in your everyday life. Take steps to:

Eat a variety of fruits, vegetables and whole grains. Fruits, vegetables and whole grains contain vitamins, minerals, fiber and antioxidants, which may play a role in cancer prevention. Choose a variety of fruits and vegetables so that you get an array of vitamins and nutrients.

Drink alcohol in moderation, if at all. If you choose to drink alcohol, limit the amount of alcohol you drink to no more than one drink a day for women and two for men.

Stop smoking. Talk to your doctor about ways to quit that may work for you.

Exercise most days of the week. Try to get at least 30 minutes of exercise on most days. If you've been inactive, start slowly and build up gradually to 30 minutes. Also, talk to your doctor before starting any exercise program.

Maintain a healthy weight. If you are at a healthy weight, work to maintain your weight by combining a healthy diet with daily exercise. If you need to lose weight, ask your doctor about healthy ways to achieve your goal. Aim to lose weight slowly by increasing the amount of exercise you get and reducing the number of calories you eat.

Colon cancer prevention for people with a high risk

Some medications have been found to reduce the risk of precancerous polyps or colon cancer. For instance, some evidence links a reduced risk of polyps and colon cancer to regular use of aspirin or aspirin-like drugs. But it's not clear what dose and what length of time would be needed to reduce the risk of colon cancer. Taking aspirin daily has some risks, including gastrointestinal bleeding and ulcers.

These options are generally reserved for people with a high risk of colon cancer. There isn't enough evidence to recommend these medications to people who have an average risk of colon cancer.

If you have an increased risk of colon cancer, discuss your risk factors with your doctor to determine whether preventive medications are safe for you.

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Show references

1. AskMayoExpert. Colorectal cancer: Screening and management (adult). Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2018.

2. Colon cancer. Plymouth Meeting, Pa.: National Comprehensive Cancer Network. https://www.nccn.org/professionals/physician_gls/default.aspx. Accessed Jan. 30, 2019.

3. Feldman M, et al. Colorectal cancer. In: Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. 10th ed. Philadelphia, Pa.: Saunders Elsevier; 2016. https://www.clinicalkey.com. Accessed Jan. 30, 2019.

4. Niederhuber JE, et al., eds. Colorectal cancer. In: Abeloff's Clinical Oncology. 5th ed. Philadelphia, Pa.: Churchill Livingstone Elsevier; 2014. https://www.clinicalkey.com. Accessed Jan. 30, 2019.

5. Colon cancer treatment (PDQ) - Patient version. National Cancer Institute. https://www.cancer.gov/types/colorectal/patient/colon-treatment-pdq. Accessed. Jan. 30, 2019.

6. Macrae FA. Colorectal cancer: Epidemiology, risk factors and protective factors. https://www.uptodate.com/contents/search. Accessed Feb. 5, 2019.

7. Kandel P, et al. Colorectal endoscopic mucosal resection (EMR). Best Practice & Research Clinical Gastroenterology. 2017;31:455.

8. Palliative care. Plymouth Meeting, Pa.: National Comprehensive Cancer Network. https://www.nccn.org/professionals/physician_gls/default.aspx. Accessed Jan. 30, 2019.

9. Moertel CG, et al. Levamisole and fluorouracil for adjuvant therapy of resected colon carcinoma. The New England Journal of Medicine. 1990;322:352.

10. Dean PA, et al. Laparoscopic-assisted segmental colectomy: Early Mayo Clinic experience. Mayo Clinic Proceedings. 1994;69:834.

11. Warner KJ. Allscripts EPSi. Mayo Clinic, Rochester, Minn. Oct. 10, 2019.

12. Grothey A, et al. Duration of adjuvant chemotherapy for stage III colon cancer. New England Journal of Medicine. 2018;378:1177.

13. Andre T, et al. The IDEA (International Duration Evaluation of Adjuvant Chemotherapy) collaboration: prospective combined analysis of phase III trials investigating duration of adjuvant therapy with the FOLFOX (FOLFOX4 or Modified FOLFOX6) or XELOX (3 versus 6 months) regimen for patients with stage III colon cancer: trial design and current status. Current Colorectal Cancer Reports. 2013;9(3):261-269.

14. Thiels CA, et al. Hepatic artery infusion pumps. Journal of Surgical Oncology. 2020; doi:10.1002/jso.25913.

15. Raphael MJ, et al. Regional therapy for colorectal cancer liver metastases: Which modality and when? Journal of Clinical Oncology. 2022; doi:10.1200/JCO.21.02505.

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Colon cancer is a type of cancer that begins in the large intestine (colon). The colon is the final part of the digestive tract. Colon cancer typically affects older adults, though it can happen at any age. It usually begins as small, noncancerous (benign) clumps of cells called polyps that form on the inside of the colon.

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https://www.mayoclinic.org/diseases-conditions/colon-cancer/diagnosis-treatment/drc-20353674

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Diagnosis

Screening for colon cancer

Doctors recommend certain screening tests for healthy people with no signs or symptoms in order to look for signs of colon cancer or noncancerous colon polyps. Finding colon cancer at its earliest stage provides the greatest chance for a cure. Screening has been shown to reduce your risk of dying of colon cancer.

Doctors generally recommend that people with an average risk of colon cancer begin screening around age 50. But people with an increased risk, such as those with a family history of colon cancer or African-American heritage, should consider screening sooner.

Several screening options exist - each with its own benefits and drawbacks. Talk about your options with your doctor, and together you can decide which tests are appropriate for you. If a colonoscopy is used for screening, polyps can be removed during the procedure before they turn into cancer.

Diagnosing colon cancer

If your signs and symptoms indicate that you could have colon cancer, your doctor may recommend one or more tests and procedures, including:

Using a scope to examine the inside of your colon (colonoscopy). Colonoscopy uses a long, flexible and slender tube attached to a video camera and monitor to view your entire colon and rectum. If any suspicious areas are found, your doctor can pass surgical tools through the tube to take tissue samples (biopsies) for analysis and remove polyps.

Blood tests. No blood test can tell you if you have colon cancer. But your doctor may test your blood for clues about your overall health, such as kidney and liver function tests.

Your doctor may also test your blood for a chemical sometimes produced by colon cancers (carcinoembryonic antigen, or CEA). Tracked over time, the level of CEA in your blood may help your doctor understand your prognosis and whether your cancer is responding to treatment.

Determining the extent of the cancer

If you've been diagnosed with colon cancer, your doctor may recommend tests to determine the extent (stage) of your cancer. Staging helps determine what treatments are most appropriate for you.

Staging tests may include imaging procedures such as abdominal, pelvic and chest CT scans. In many cases, the stage of your cancer may not be fully determined until after colon cancer surgery.

The stages of colon cancer are indicated by Roman numerals that range from 0 to IV, with the lowest stages indicating cancer that is limited to the lining of the inside of the colon. By stage IV, the cancer is considered advanced and has spread (metastasized) to other areas of the body.

Treatment

Which treatments are most likely to help you depends on your particular situation, including the location of your cancer, its stage and your other health concerns. Treatment for colon cancer usually involves surgery to remove the cancer. Other treatments, such as radiation therapy and chemotherapy, might also be recommended.

Surgery for early-stage colon cancer

If your colon cancer is very small, your doctor may recommend a minimally invasive approach to surgery, such as:

Removing polyps during a colonoscopy (polypectomy). If your cancer is small, localized, completely contained within a polyp and in a very early stage, your doctor may be able to remove it completely during a colonoscopy.

Endoscopic mucosal resection. Larger polyps might be removed during colonoscopy using special tools to remove the polyp and a small amount of the inner lining of the colon in a procedure called an endoscopic mucosal resection.

Minimally invasive surgery (laparoscopic surgery). Polyps that can't be removed during a colonoscopy may be removed using laparoscopic surgery. In this procedure, your surgeon performs the operation through several small incisions in your abdominal wall, inserting instruments with attached cameras that display your colon on a video monitor. The surgeon may also take samples from lymph nodes in the area where the cancer is located.

Surgery for more advanced colon cancer

If the cancer has grown into or through your colon, your surgeon may recommend:

Partial colectomy. During this procedure, the surgeon removes the part of your colon that contains the cancer, along with a margin of normal tissue on either side of the cancer. Your surgeon is often able to reconnect the healthy portions of your colon or rectum. This procedure can commonly be done by a minimally invasive approach (laparoscopy).

Surgery to create a way for waste to leave your body. When it's not possible to reconnect the healthy portions of your colon or rectum, you may need an ostomy. This involves creating an opening in the wall of your abdomen from a portion of the remaining bowel for the elimination of stool into a bag that fits securely over the opening.

Sometimes the ostomy is only temporary, allowing your colon or rectum time to heal after surgery. In some cases, however, the colostomy may be permanent.

Lymph node removal. Nearby lymph nodes are usually also removed during colon cancer surgery and tested for cancer.

Surgery for advanced cancer

If your cancer is very advanced or your overall health very poor, your surgeon may recommend an operation to relieve a blockage of your colon or other conditions in order to improve your symptoms. This surgery isn't done to cure cancer, but instead to relieve signs and symptoms, such as a blockage, bleeding or pain.

In specific cases where the cancer has spread only to the liver or lung but your overall health is otherwise good, your doctor may recommend surgery or other localized treatments to remove the cancer. Chemotherapy may be used before or after this type of procedure. This approach provides a chance to be free of cancer over the long term.

Chemotherapy

Chemotherapy uses drugs to destroy cancer cells. Chemotherapy for colon cancer is usually given after surgery if the cancer is larger or has spread to the lymph nodes. In this way, chemotherapy may kill any cancer cells that remain in the body and help reduce the risk of cancer recurrence.

Chemotherapy might also be used before an operation to shrink a large cancer so that it's easier to remove with surgery.

Chemotherapy can also be used to relieve symptoms of colon cancer that can't be removed with surgery or that has spread to other areas of the body. Sometimes it's combined with radiation therapy.

Radiation therapy

Radiation therapy uses powerful energy sources, such as X-rays and protons, to kill cancer cells. It might be used to shrink a large cancer before an operation so that it can be removed more easily.

When surgery isn't an option, radiation therapy might be used to relieve symptoms, such as pain. Sometimes radiation is combined with chemotherapy.

Targeted drug therapy

Targeted drug treatments focus on specific abnormalities present within cancer cells. By blocking these abnormalities, targeted drug treatments can cause cancer cells to die.

Targeted drugs are usually combined with chemotherapy. Targeted drugs are typically reserved for people with advanced colon cancer.

Immunotherapy

Immunotherapy is a drug treatment that uses your immune system to fight cancer. Your body's disease-fighting immune system may not attack your cancer because the cancer cells produce proteins that blind the immune system cells from recognizing the cancer cells. Immunotherapy works by interfering with that process.

Immunotherapy is usually reserved for advanced colon cancer. Your doctor might have your cancer cells tested to see if they're likely to respond to this treatment.

Supportive (palliative) care

Palliative care is specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness. Palliative care is provided by a team of doctors, nurses and other specially trained professionals that work with you, your family and your other doctors to provide an extra layer of support that complements your ongoing care.

Palliative care teams aim to improve the quality of life for people with cancer and their families. This form of care is offered alongside curative or other treatments you may be receiving.

When palliative care is used along with all of the other appropriate treatments, people with cancer may feel better and live longer.

Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this disease.

Coping and support

A cancer diagnosis can be emotionally challenging. In time, people learn to cope in their own unique ways. Until you find what works for you, you might try to:

Learn enough about your cancer to feel comfortable making treatment decisions. Ask your doctor to tell you the type and stage of your cancer, as well as your treatment options and their side effects. The more you know, the more confident you'll be when it comes to making decisions about your own care. Look for information in your local library and on reliable websites.

Keep friends and family close. Keeping your close relationships strong will help you deal with cancer. Friends and family can provide the practical support you'll need, such as helping take care of your home if you're in the hospital. And they can serve as emotional support when you feel overwhelmed.

Find someone to talk with. Find a good listener who is willing to listen to you talk about your hopes and fears. This may be a friend or family member. The concern and understanding of a counselor, medical social worker, clergy member or cancer support group also may be helpful.

Ask your doctor about support groups in your area or contact a cancer organization, such as the National Cancer Institute or the American Cancer Society.

Preparing for your appointment

If your doctor suspects you may have colon cancer, you'll likely be referred to specialists who treat colon cancer. You may meet with a number of specialists, including a:

Doctor who treats digestive diseases (gastroenterologist)

Doctor who uses medications to treat cancer (oncologist)

Doctor who removes colon cancer using surgery (surgeon)

Doctor who uses radiation to treat cancer (radiation oncologist)

Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well-prepared. Here's some information to help you get ready, and know what to expect from your doctor.

What you can do

Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your diet.

Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.

Write down key personal information, including any major stresses or recent life changes.

Make a list of all medications, vitamins or supplements that you're taking.

Consider taking a family member or friend along. Sometimes it can be difficult to take in all the information provided during an appointment. Someone who accompanies you may remember something that you missed or forgot.

Write down questions to ask your doctor.

Some basic questions to ask your doctor include:

Where is my colon cancer located in my colon?

What is the stage of my colon cancer?

Can you explain my pathology report to me?

Can I have a copy of my pathology report?

Has my colon cancer spread to other parts of my body?

Will I need more tests?

What are the treatment options for my colon cancer?

Will any of the treatments cure my colon cancer?

What is the chance that my colon cancer will be cured?

How much does each treatment increase my chances that my colon cancer will be cured?

What are the potential side effects of each treatment?

How will each treatment affect my daily life?

Is there one treatment you feel is best for me?

What would you recommend to a family member or friend in my same situation?

How much time can I take to make my decision about treatment?

Should I seek a second opinion?

Should I see a specialist? What will that cost, and will my insurance cover it?

Are there any brochures or other printed material that I can take with me? What websites do you recommend?

Do my siblings or my children have an increased risk of colon cancer?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may allow time to cover other points you want to address. Your doctor may ask:

When did you first begin experiencing symptoms?

Have your symptoms been continuous or occasional?

How severe are your symptoms?

What, if anything, seems to improve your symptoms?

What, if anything, appears to worsen your symptoms?

Do you have a family history of colon cancer or other cancers?

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Doctors recommend certain screening tests for healthy people with no signs or symptoms in order to look for signs of colon cancer or noncancerous colon polyps. Finding colon cancer at its earliest stage provides the greatest chance for a cure. Screening has been shown to reduce your risk of dying of colon cancer.

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https://coloncancercoalition.org/get-educated/what-you-need-to-know/colon-cancer-facts/

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A list of facts can be scary. As you consider the information here, remember that with on-time screeningand timely evaluation of symptoms, colon cancer is preventable, treatable and beatable!

About Colorectal Cancer

Colon cancer is cancer of the colon. Rectal cancer is cancer in the rectum. Together they are colorectal .

It is the third most commonly diagnosed cancer and the second leading cause of cancer death.

Colorectal cancer affects men and women equally, and people of all races and nationalities.

Half of all new colorectal cancer diagnosis are in people 66 or younger.

The 5-year relative survival rate for stage 1 and stage II colon cancer is 90%; the 5-year survival rate for patients diagnosed at stage III is 71% and stage IV is 14%.

Often, those who are diagnosed with colorectal cancer have experienced no signs or symptoms associated with the disease.

Family History

People with a parent, sibling, or offspring with colorectal cancer have 2 or 3 times the risk of developing colon cancer compared to those with no family history of the disease.

While most people diagnosed with colon cancer have no family history of the disease, those with a family history should begin screening at an earlier age.

When a relative is diagnosed at a young age or if there is more than one affected relative, the risk of developing colorectal cancer increases to three to six times that of the general population.

Colorectal Cancer in Young People

In 2020, there will be about 18,000 cases of colorectal cancer diagnosed in people under 50, the equivalent of 49 new cases per day.

One in five colorectal cancer patients are between 20 and 54 years old.

It is the 3rd leading cause of cancer death in young adults.

The risk of colorectal cancer increases with age; 90% of cases are diagnosed in individuals 50 years of age and older.

While rates of colorectal cancer have been declining among adults 50 years and older, incidence of colorectal cancer is increasing among adults under age 50.

People born after 1990 have 2 times the risk of developing colon cancer and 4 times the risk of developing rectal cancer than those born in 1950.

In 2020, there will be an estimated 49 new cases of colorectal cancer in people under 50 diagnosed a day, or 18,000 for the year.

Younger adults were more likely than older adults to be diagnosed with late-stage colon or rectal cancers because they are under the recommended screening age.

What About Screening?

According to the American Cancer Society, men and women should begin screening for colorectal cancer at age 45.

There are many screening tests available, including some non-invasive, inexpensive tests that can be done in the privacy of your own home.

The National Colorectal Round Table estimates that if the 80% of the eligible population was screened at the age of 50, the number of colorectal cancer-related deaths could be cut by 230,000.

Screening has the potential to detect and even prevent colorectal cancer because polyps (precursors to cancer) can be removed during a colonoscopy screening.

Being screened at the recommended frequency increases the likelihood that when colorectal cancer is present, it will be detected at an earlier stage.

When colorectal cancer is detected in its early stages it is more likely to be cured, treatment is less extensive, and the recovery is much faster.

The risk of developing or dying from colorectal cancer can be reduced by maintaining a healthy body weight, regular physical activity, limiting intake of red and processed meats, and by not smoking.

In the past ten years, colorectal cancer screening rates have increased, but rates still remain low, especially among those who are uninsured.

Colorectal cancer incidence rates in individuals of screening age have been declining in the US since the mid-1980s, due to increased awareness and screening.

Colorectal cancer usually develops slowly over a period of 10 to 15 years.

Colorectal cancer rates in the US vary widely by geographic area. Contributing factors include regional variations in risk factors and access to screening and treatment.

Racial/ethnic groups have a higher mortality rate from colorectal cancer because they are less likely to be screened on-time, have less access to screening, and less likely to have colorectal cancer detected at its earliest stages.

51% of those ages 50-54 are not up to date on their colorectal cancer screening.

Total treatment cost for colorectal cancers in the United States is about $14 billion per year.

References

American Cancer Society: Key Statistics for Colorectal Cancer
American Cancer Society Press Release: Colorectal Cancer Burden Shifting to Younger Individuals
American Cancer Society: Survival Rates for Colorectal Cancer
National Institutes of Health: Cancer Cost Projections

Next >> What are the Symptoms?
Information on these pages is provided for informational purposes only. Consult your own physician before making any medical decisions.

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Colon Cancer Facts | Colon Cancer Coalition

# data[].attributes.attachment_link.description
Colon cancer is cancer of the colon. Rectal cancer is cancer in the rectum. Together they are colorectal . It is the third most commonly diagnosed cancer and the second leading cause of cancer death. Colorectal cancer affects men and women equally, and people of all races and nationalities.

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Abstract

Background

Understanding patients' expectations of their treatment is critical to ensure appropriate treatment decisions, and to explore how expectations influence coping, quality of life and well‐being. This study aimed to examine these issues related to treatment in patients with colorectal cancer.

Methods

A literature search from January 1946 to September 2016 was performed to identify available data regarding patients' expectations of outcomes following colorectal cancer treatment. A narrative synthesis of the evidence was planned.

Results

Of 4337 items initially identified, 20 articles were included in the review. In studies presenting data on overall and short‐term survival, patients considerably overestimated prognosis. Patients also had unrealistic expectations of the negative aspects of chemotherapy and stomas. There was marked discordance between patients' and clinicians' expectations regarding chemotherapy, end‐of‐life care, bowel function and psychosocial outcomes. Level of education was the most consistent factor influencing the accuracy of patients' expectations.

Conclusion

Patients with colorectal cancer frequently have unrealistic expectations of treatment. Marked disparities exist between patients' and clinicians' expectations of outcomes.

Introduction

Most patients with colorectal cancer are now expected to survive for 10 years or more as a result of earlier diagnosis and increasingly effective treatments1. Recommendations about treatment require both clinicians and patients to share an understanding of prognosis, management options and the goals of care2. Evaluating patients' expectations and using this information to guide treatment decision‐making is essential to achieve optimal outcomes3. Asking about expectations may lead to improved engagement in care and more realistic expectations of outcomes4. Unrealistic expectations may impair patients' ability to cope with the consequences of treatment, resulting in impaired quality of life. To date, little work has been done to explore the expectations of patients and clinicians regarding outcomes following treatment.

Systematic reviews typically address a specific question; however, scoping reviews are used widely to provide a map of the existing evidence on a broader topic in order to identify gaps in the knowledge base and identify areas for further study5, 6, 7. They use less strict inclusion criteria, bringing together data from more heterogeneous sources and, unlike systematic reviews which seek the best evidence, scoping reviews include all available evidence and so quality assessments are rarely performed5. The aim of this review was to assess studies reporting patients' expectations of treatment outcomes for colorectal cancer.

Methods

Search strategy

A preliminary search was conducted in the PubMed and Embase databases to inform the development of a set of keywords, index terms and phrases. These included: patient experience, perception or decision; informed decision or survival expectation; prognostic understanding, patient-physician communication or goals of care. Using these agreed terms, a second comprehensive search ( Appendix S1, supporting information) was then conducted in Ovid MEDLINE (1 January 1946 to 14 September 2016), Ovid Embase (1 January 1974 to 14 September 2016), Ovid PsycINFO (1 January 1806 to 14 September 2016) and EBSCO CINAHL (1 January 1981 to 14 September 2016). The results were exported to reference management software, duplicates removed, and articles screened according to inclusion and exclusion criteria. The search strategy was supplemented by manual searches of bibliographic references. Grey literature was searched using Google Advanced and OpenGrey.

Eligibility

Articles were included if primary data were presented on adult patients with colorectal cancer, and patient expectations regarding prognosis or effects of an intervention were assessed in any qualitative or quantitative manner. Articles that were not published in English were excluded. There was no restriction on study design, but articles had to be published in peer‐reviewed journals.

Screening

After removal of duplicates, one author independently screened the remaining titles and abstracts, and extracted those that did not obviously meet the inclusion criteria. This list was checked by a second author. A full‐text screen of the remaining articles was carried out against the inclusion criteria. Any disagreements were resolved through discussion with the senior author.

Data extraction and synthesis

The first author extracted data from the included studies and the second author reviewed the data for accuracy. A wide variety of outcomes can be assessed following colorectal cancer treatment8. The present review considered any article aimed to evaluate any outcome that had been assessed. Given the heterogeneity in patient groups, study design and data presented, a narrative synthesis was conducted of the findings from included studies. The results focused on the key areas in the available studies, including: expectations of overall survival, the impact of chemotherapy, psychosocial outcomes, end‐of‐life care and bowel function.

Results

Search results

Of 4337 potential articles, 20 studies9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28 were finally included in the review ( Fig. ​.1). 1 ). These studies are summarized in Table​1. 1 . The majority of articles came from North America (10 from the USA, 2 from Canada). Three were from Australia, and the remaining five from different European countries (Germany (2), the Netherlands, Italy and Austria).

Table 1

Reference

Main aim

No. of patients with CRC

Group

Key findings

Methodology

Timing

Emery18

To analyse patients' expectations of chemotherapy

30

Primary only

Patients believe that chemotherapy has to hurt to have benefit

Semistructured interviews

During/shortly after chemotherapy

Thirteen studies investigated only patients with colorectal cancer, whereas seven also involved patients with other cancers, predominantly lung (6 of 7 studies). Ten studies concentrated on patients with end‐stage disease, four focused on those having primary surgery only, four assessed patients with a range of stages and two looked specifically at patients with temporary stomas. In 12 studies, a variety of questionnaires were used (almost entirely in‐house questionnaires) and nine included semistructured interviews. The median study population was 171 (range 20-2755) patients. Treating clinicians' expectations of patients' outcomes were also evaluated in five studies.

Only two studies were longitudinal. One17 was primarily concerned with assessing the benefits of a decision aid, and the other15 on the impact of a stoma and stoma reversal. There was one crossover study (patients receiving oral then intravenous chemotherapy or the reverse)21. The other 17 studies were cross‐sectional.

Overall survival

Table​2 2 summarizes the five studies that had data on patients' expectation of survival. Only one study13 compared expectation of survival with actual survival. Patients achieved a median survival of 30 months, but expected a median of 44 months. Three studies26, 27, 28 evaluated expectations regarding the probability of surviving the next 2 or 6 months among patients being treated with palliative intent. In each of these studies, patients again overestimated their probability of survival. It was found that their expectation may have a significant impact on the treatment they received. Patients with the longest expectation of survival were more likely to receive potentially life‐extending therapy rather than simply supportive care28.

In all studies that compared patients' and clinicians' estimates of prognosis13 20, 25 26, 28, the clinicians had a more accurate expectation of prognosis. This was quantified in only one study27, which showed the area under a curve for a physician's estimation of prognosis to be 0·80, compared with 0·66 for a patient.

Chemotherapy

Eight studies examined patients' expectations of the impact of chemotherapy ( Table​3). 3 ). They approached patient expectation from a variety of viewpoints, including investigating the perceptions of beneficial effects, burden of side‐effects and preference for route of administration. Patients tended to overestimate the beneficial effects of treatment. They may also have had unrealistic expectations regarding side‐effects. Patients receiving chemotherapy frequently thought that 'it's got to hurt to have benefit'18. One study17 showed that patients' preconceived ideas regarding chemotherapy before a consultation significantly influenced their likelihood of uptake, and a further study25 found that some were willing to potentially limit longevity owing to concerns about the side‐effects of chemotherapy. Following personal experience of chemotherapy, patients' perspectives on choosing methods of administration often changed21. Higher education level significantly influenced patient decision‐making both in terms of having more realistic expectations and improved decisional certainty17 21.

Table 3

Reference

Findings

Emery18

Patients felt chemotherapy had to hurt and have significant side‐effects to have a beneficial effect, and that intravenous was more powerful than oral administration

Quality of life

Only two studies19 23 attempted to evaluate quality‐of‐life expectations. Using an in‐house questionnaire, one23 found that age and level of education significantly influenced patient expectations of outcomes before treatment. All groups in that study gave highest priority to achieving cure, although older patients less frequently expected cure than younger patients. Younger patients were also more likely to expect to avoid a stoma and were more concerned by the prospect of incontinence23. Cosmetic issues, quick return to work, ability to attend social events and an undisturbed sex life were all expected significantly more often among younger patients23.

The other study19 investigating quality of life used its own questionnaires as well as the EuroQoL Five Dimensions (EQ‐5D™; EuroQol Group, Rotterdam, the Netherlands), although the primary aim was to investigate the patient's perception of likelihood of cure and the influence of physician communication. Some 83 per cent of patients felt surgery was likely or very likely to help with 'some of the problems' they were currently experiencing as a result of their cancer, and 95 per cent felt it was likely to prolong life19.

End‐of‐life management

Ten studies included patients with advanced colorectal cancer, of which five addressed end‐of‐life care. One study26 that looked mainly at patients in their last 6 months of life showed how treatment preferences changed as individuals got closer to death, with an increasing focus on comfort rather than longevity. Patients were less keen to prolong life with care options such as the requirement for a feeding tube and there was an increasing preference for 'do not resuscitate' orders to be applied. This latter finding was confirmed in a second study27, while highlighting that physicians incorrectly overestimated preferences not to be resuscitated in one‐third of patients27.

Bowel function

Two studies specifically addressed patients' attitudes to a temporary stoma, with questionnaires delivered before and at varying time points following the procedure. One study15 looked at patients' preoperative expectations of the effect of a temporary stoma. The authors identified a response shift in perception of quality of life that they attributed to the life‐threatening disease and the time spent living with a temporary stoma. In a further study22, notwithstanding a lack of clarity around the timing of questionnaires and interviews, some 55 per cent of patients felt the experience of living with a stoma positively exceeded their expectations and 30 per cent thought it met their expectations. After stoma reversal, however, 6 per cent of patients felt worse than expected, with expectations being exceeded in only 5 per cent and being met in 35 per cent. In two studies21 25, patients were prepared to compromise survival to avoid a stoma. One study25 reported that patients were prepared to accept a high incontinence rate and even willing to compromise on survival in order to avoid a stoma, and a further study21 implied that 60 per cent of patients were prepared to give up one‐third of their life expectancy in order to avoid a stoma.

One study12 explored preoperative patient expectations of bowel function following rectal cancer surgery. Sources of patients' expectations and understanding, such as information from healthcare providers, were evaluated. A high degree of patient uncertainty and worry about future bowel function was present, with wide variations in individual patient views on how this might affect their lives. Bowel function problems, however, were often seen as a secondary issue compared with anxieties around cancer cure and recovery from major surgery.

Discussion

Evaluating patients' expectations following colorectal cancer treatment involves considering both patients treated with curative and those treated with palliative intent. Understanding patients' expectations encompasses perceptions of prognosis as well as the physical consequences of cancer and proposed treatments. Although colorectal cancer is a common cancer, there is a paucity of literature on this topic. Although formal assessments of study quality have not been carried out, in line with typical scoping review methodology5, it is apparent that this area also lacks robust, longitudinal studies with validated questionnaires that may determine how patient expectations change over time and how they may change in response to treatments or the provision of information as their condition evolves. As the studies identified focused on a range of issues using a variety of study designs, a systematic review could not be performed.

Disparities between patients' and clinicians' expectations of prognosis were consistent findings. Of five studies13 20, 25 26, 28 that compared the two, all demonstrated marked differences in expectations. Many patients receiving chemotherapy with palliative intent actually felt the goal was still cure17. Similar disparity between patients' and clinicians' expectations was also demonstrated in 'do not resuscitate' decisions among those with end‐stage disease. Clinicians incorrectly estimated the patient's preference not to be resuscitated in one‐third of patients27. The impact of education level influencing patient expectations was touched on in several studies21 23, but only one study12 evaluated how patients with colorectal cancer developed their expectations of outcome.

Patients' expectations have been shown to be a strong predictor of the success of surgical interventions29 30, and in heart disease can even influence survival31. Modifying patients' expectations before cardiac surgery has resulted in less disability and better quality of life, earlier return to work, lower readmission rates and, interestingly, significantly reduced levels of the proinflammatory cytokines interleukin (IL) 6 and IL‐832.

To evaluate patient outcomes accurately it is important to understand the patient's expectations before treatment, what is most important to the patient, and what their individual priorities and anxieties are. It is essential to make this assessment before the intervention as this will reduce the impact of cognitive dissonance, where the patient's beliefs and values may be recalibrated following the intervention33.

More high‐quality research needs to be done in this area. Better understanding is needed of patients' expectations of outcomes, their influence on treatment decisions, quality‐of‐life outcomes, and the variability in outcome expectations across disease stages and patient factors. Subsequently, interventions that realign patients' and clinicians' expectations to ensure shared decision‐making can be investigated, which will probably lead to improved outcomes.

Disclosure

The authors declare no conflict of interest.

Supporting information

Appendix S1 Search strategy

Notes

Funding information: No funding

References

5. Peters MDJ, Godfrey CM, McInerney P, Soares CB, Khalil H, Parker D. The Joanna Briggs Institute Reviewers' Manual 2015: Methodology for JBI Scoping Reviews. The Joanna Briggs Institute, University of Adelaide: Adelaide, 2015. [ Google Scholar]

6. Arksey H, O'Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol 2005; 8: 19-32. [ Google Scholar]

26. McCarthy EP, Phillips RS, Zhong Z, Drews RE, Lynn J. Dying with cancer: patients' function, symptoms, and care preferences as death approaches. J Am Geriatr Soc 2000; 48(Suppl): S110-S121. [[ PubMed] Google Scholar]

Articles from BJS Open are provided here courtesy of Oxford University Press

# data[].attributes.attachment_link.title
Expectations of outcomes in patients with colorectal cancer

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Understanding patients' expectations of their treatment is critical to ensure appropriate treatment decisions, and to explore how expectations influence coping, quality of life and well‐being. This study aimed to examine these issues related to treatment in patients with colorectal cancer.

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https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwjM6LfHicD8AhUQQzABHdP-D60QFnoECAwQAw&url=https%3A%2F%2Fwww.cdc.gov%2Fcancer%2Fcolorectal%2Fbasic_info%2Frisk_factors.htm&usg=AOvVaw0VT5tDlGUaih2iYxHQMFxl

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Colon Cancer is the 4th most common diagnosed cancer, and the second highest cause of cancer related deaths.

Those with colon cancer running their family line have 2 or 3 times the risk of developing it compared to those without a family history in colon cancer

By 2030, colon cancer is believed to be the leading cause of cancer related death in adults under 50

1 in 5 patients are diagnosed with colon cancer between the age of 20 and 54

The risk of colon cancer increases with age

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death

recurrence following surgery

Numbness in their fingers and toes

A persistent change in bowel habits

Abdominal discomfort

Cramps/pain

Weakness or fatigue

Unexplained weight loss

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A change in bowel habits; like a change in the consistency of your stool, constipation, or diarrhea

Feeling like you haven't fully digested your meal after a long period of time

Constant stomach pain such as aches, cramps, gases, or discomfort

Seeing blood in your stool or persistent bleeding

A sudden weakness or laziness that won't seem to go away

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Causes

Lack of regular physical activity.

A diet low in fruit and vegetables.

A low-fiber and high-fat diet, or a diet high in processed meats.

Overweight and obesity.

Alcohol consumption.

Tobacco use.

Risk Factors

Old Age

African-American race

A personal history of colorectal cancer or polyps

Inflammatory intestinal conditions

Inherited syndromes that increase colon cancer risk

Family history of colon cancer

Low-fiber, high-fat diet

A sedentary lifestyle

Diabetes

Obesity

Smoking

Alcohol

Radiation therapy for cancer

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Found at an Early Stage

If the cancer is contained and small, one could undergo a colonoscopy to remove the polyp (a small piece of tissue forming inside ones body, typically in the colon or large intestine). This procedure is known as a polypectomy

Laparoscopic Surgery: procedure where polyps that cannot be removed in a colonoscopy. Here, surgeons insert attached cameras to monitor the inside of the abdominal wall

Advanced Cancer

With more advanced cancer, the surgeon can remove the portion of the colon that contains the cancer through a partial colectomy or laparoscopy.

Through a lymph node removal, the lymph nodes that are near the cancer or infected portion can be removed and tested.

Other Options

Chemotherapy: to destroy cancer cells, drugs are used after surgery if the cancer continued to spread, or shrink the cancer prior to the surgery. This prevents a recurrence of cancer

Radiation Therapy: By using x-rays or protons (Energy sources), cancer cells can be terminated or shrunk before a surgery. When a patient cannot undergo an operation, radiation therapy can be used to relax the symptoms and pain.